You may think that the bubonic plague or black death is a relic of the middle ages, but a huge outbreak in Madagascar has authorities on high alert. Nearly 2,000 cases have been reported in the African island nation, including 143 deaths, according to the World Health Organization.

The good news is that reported cases have been on the decline lately based on the number of people hospitalized in Madagascar as only 27 people were hospitalized on Nov. 6 compared to 106 on Oct. 29, VOA reports. But the risk remains great in the country, especially since traditional burial practices of the dead cause the disease to spread.

It is tradition in Madagascar to exhume corpses and hold an annual celebration to honor them, but this is a concern to health officials who worry this will cause new outbreaks. There are typically about 600 cases of plague each year usually in rural parts of the country, which shows just how extensive this latest outbreak has been.

“Plague has a remarkable place in history and has had enormous effects on the development of modern civilization,” the CDC says about the disease. “Some scholars have even suggested that the collapse of the Roman Empire may be linked to the spread of plague by Roman soldiers returning home from battle in the Persian Gulf in 165 AD. For centuries, plague represented disaster for people living in Asia, Africa and Europe and because the cause of plague was unknown, plague outbreaks contributed to massive panic in cities and countries where it appeared.”